Osman Küçükosmanoğlu

Marked Bradycardia Due to Pulsed and Oral Methylprednisolone Therapy in a Patient with Rapidly Progressive Glomerulonephritis

Accessible online at: http://BioMedNet.com/karger Dear Sir, Pulsed methylprednisolone (MP) is becoming very popular in the treatment of various immunomediated disorders, especially in the field of pediatric nephrology. Although associations with serious cardiac arrhythmias and even sudden death have been reported in sporadic cases [1, 2], its exact mechanism of action is not clear. We were also not able to find any case report stating oral MP as a possible cause of cardiac side effects. Herein we report a patient with rapidly progressive glomerulonephritis who developed marked sinus bradycardia necessitating cardiac pacing after a first dose of pulsed MP and showed continuity of sinus bradycardia with oral MP regimen. A 14-year-old boy was admitted to our hospital with hematuria and edema. Physical examination revealed blood pressure of 140/90 mm Hg and a regular pulse of 104 b.p.m. He had mild pretibial edema, the other findings including the cardiovascular system were all normal. Laboratory examination revealed; hemoglobin 11 g/dl, normal leukocyte and platelet counts; blood urea nitrogen 105 mg/dl, serum creatinine 5.2 mg/ dl, serum uric acid 9.2 mg/dl and serum albumin 4.2 g/dl, erythrocyte sedimentation rate 130 mm/h, serum electrolytes and calcium were normal. Creatinine clearance was 17.2 ml/min/1.73 m2. Urinary findings were hematuria, protein 4+, large erythrocytes, 10–15 leukocytes and occasional hyaline cast in the sediment. Quantitative proteinuria was 341 mg/m2/h. An abdominal sonogram revealed normally sized kidneys. Echocardiographic findings were normal. Serological tests showed a negative antinuclear antibody, negative anti-DNA antibody and normal C3 level. Chest X-ray and electrocardiogram were normal. Clinical diagnosis was rapidly progressive glomerulonephritis, and he was given a dose of 30 mg/kg pulsed intravenous MP. Two other consecutive daily pulses were planned. Five hours later, heart rate decreased to 50 b.p.m. and an ECG obtained at this time showed sinus bradycardia with no heart block or arrest. Since the heart rate had decreased below 40 b.p.m. a transvenous temporary pacemaker was positioned and pulsed MP therapy was discontinued. His heart rate gradually increased to 80 b.p.m. in 3 days. He was followed up for another 3 days with normal heart rate, then he was given oral MP 60 mg/m2 daily. Surprisingly his heart rate decreased again gradually and reached 40 b.p.m. in 5 days. This marked sinus bradycardia forced us to discontinue oral MP therapy on the 8th day of treatment. A percutaneous renal biopsy was performed and the diagnosis of membranoproliferative glomerulonephritis was established. He was started on oral cyclophosphamide and dipyridamole treatment. After cessation of oral MP, his heart rate increased to normal levels. Intravenous steroids are frequently used in the treatment regimen of all types of glomerulonephritis, vasculitis and collagen tissue disorders [3, 4]. Although the side effects of steroids are all well known, there are only few reports in the literature of side effects on the cardiovascular system. The half-life of intravenous MP is 3 h and the duration of the effect on the hypothalamic-pituitary-adrenal axis is 12–36 h after a single dose. In our case, sinus bradycardia was seen 5 h after infusion. After 3 days, the patient’s heart rate was normal, but following oral MP treatment the heart rate decreased again. This observation indicates that oral MP treatment could be the cause of decreased heart rate. Premature ventricular contractions, atrial fibrillation, myocardial infarction, junctional arrhythmias, asystole and sudden death were reported with pulsed intravenous MP treatment [5, 6]. The mechanism is not obvious, but it was suggested that MP may have a direct effect on the integrity of cardiac or smooth muscles, causing alterations in calcium and potassium flux across cell membranes. The speed of administration has been suggested as an important factor [7]. Our experience suggests that both intravenous and oral MP treatments may cause adverse effects on the cardiovascular system. We recommend that patients receiving highdose MP should be carefully monitored for cardiac side effects.

Compatibility of Automatic Threshold Tracking Pacemakers with Previously Implanted Pacing Leads in Children

KUCUKOSMANOGLU, O., et al.: Compatibility of Automatic Threshold Tracking Pacemakers with Previously Implanted Pacing Leads in Children. The Autocapture function controls and optimizes the amplitude of the pacing pulse and saves energy. The manufacturer recommends using a special low polarization, low threshold bipolar Pacesetter lead for the Autocapture function. The purpose of this study was to evaluate the compatibility of Autocapture with previously implanted pacing leads. The study included 15 patients (mean age 13.6 ± 3.4 years) who needed pulse generator replacement and received the VVIR pacemaker Regency SR+ or the DDDR pacemakers Affinity DR or Integrity DR with the Autocapture function. The new pulse generators connected to previously implanted ventricular leads. At the time of implantation the pacing threshold was 1.0 ± 0.35 V at 0.5 ms, the lead impedance was 580 ± 80 Ω, and the spontaneous R wave amplitude was 7.89 ± 4.89 mV. The polarization signal (PS) was 3.8 ± 3.04 mV, and evoked response (ER) was 8.15 ± 4.57 mV at the predischarge testing. Follow‐up telemetry was done at months 1, 3, 6, 12, and 18. The follow‐up duration was 9.4 ± 5 months (range 1–18 months). If the results of PS and ER measurements were acceptable for Autocapture, it turned on at the 1‐month visit. In six (40%) patients the results were found acceptable for Autocapture function. Age, lead impedance, pacing threshold, intrinsic R wave measurement, lead age, fixation mechanism, and ER measurements were not statistically different in Autocapture suitable and not suitable groups. The main reason not to activate Autocapture had been increased PS. Any significant fluctuations were not observed in pacing threshold, lead impedance, ER, and PS during follow‐up. In conclusion, previously implanted pacing leads may be compatible with the Autocapture function.

Prevalence and distribution of structural heart diseases in high and low risk pregnancies

OBJECTIVE To establish and compare the frequency of intrauterine congenital heart defects in high-risk and low-risk pregnancies for congenital heart diseases. METHODS Records of 3782 patients who underwent fetal echocardiography at the Pediatric Cardiology Unit were reviewed for reasons of referral and results of echocardiography retrospectively. The categorical variables between the groups were analyzed using a Chi-square test. RESULTS Structural heart defects were found in 213 (5.6%) fetuses in both high and low risk groups. Most common defects were ventricular septal defect (36.2%) and atrioventricular septal defect (14.1%). Frequency of congenital heart diseases was 7.8% (169 fetuses) in high-risk group: 4.1% were complex, 2.3% significant and 1.4% were minor. In low-risk group, the frequency was 2.7% (44 fetuses): 0.6% were complex, 0.8% significant and 1.3% were minor. In this group, rates of congenital defects were high regarding particular reasons: intrauterine fetal death in previous pregnancy (6.3%), abnormal first or second trimester screening tests (4.3%), and multiple gestations (3.4%). The sensitivity and specificity of fetal echocardiography according to transthoracic echocardiography were found to be 86% and 99%, respectively. CONCLUSION Congenital heart diseases rate, as expected, was found to be higher in high-risk group. However, regarding intrauterine fetal death in previous pregnancy, abnormal first or second trimester screening tests and multiple gestation, no statistically significant difference was observed between low-risk and high-risk groups. Therefore, we suggest the routine use of fetal echocardiography in cases we have mentioned above if the staff and equipment of the pediatric cardiology clinic are eligible.

Mitral annular calcification and brown tumor of the rib in a child with chronic renal failure

Mitral annular calcification and liquefaction necrosis of this lesion mimicking intracardiac tumor because of secondary hyperparathyriodism have been described in adult patients with chronic renal failure, but have not been reported in children. Chronic renal failure is one of the predisposing factors of this condition. We report the case of a 13-year-old patient with continuous ambulatory peritoneal dialysis with severe hyperparathyroidism who was found to have intracardiac and rib lesions considered to be brown tumors.

Congenital aorto-left atrial tunnel--an unusual communication: a case report.

Congenital aortico-cameral communications are rarely seen. We present an asymptomatic patient in whom there was a congenital vascular communication rising from the aortic root and terminating in the left atrium. She had an atrial septal defect (ASD). The diagnosis was made with echocardiography and confirmed by aortography. She was treated by closing the tunnel and the ASD. The outcome was satisfactory in this extremely rare case of a congenital cardiac lesion. Coincidental diagnosis could be made during careful echocardiographic examination.

Rhythm and conduction abnormalities after transcatheter closure of VSDs: A single-center experience

Address for Correspondence: Dr. Sevcan Erdem, Çukurova Üniversitesi Tıp Fakültesi, Pediyatrik Kardiyoloji, Yüreğir, Adana-Türkiye Phone: +90 322 338 60 60 E-mail: serdem@cu.edu.tr Accepted Date: 11.06.2013 Available Online Date: 09.12.2013 ©Copyright 2014 by AVES Available online at www.anakarder.com doi:10.5152/akd.2013.4538 Sevcan Erdem, Nazan Özbarlas, Alev Kızıltaş, Abdi Bozkurt*, Osman Küçükosmanoğlu

Ellis Van Creveld sendromu olgusu

Ellis Van Creveld sendromu cogunlugu elde olmak uzere postaksiyal polidaktili ekstremitelerde mezo akromelik kisalik kucuk gomulu tirnaklar multipl oral frenula kisa kostalar uzun dar toraks ve baslica atriyal septal defekt olmak uzere konjenital kalp defektini iceren otozomal resesif bir sendromdur Olgularin yaklasik yarisi kardiyorespiratuvar problemlerle erken sut cocuklugu doneminde kaybedilmektedir Burada tipik ozelliklere sahip bir Ellis Van Creveld sendromu olgusu sunulmustur Anahtar kelimeler: Ellis Van Creveld sendromu polidaktili tek atrium